Chest Tube Insertion

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Chest Tube Insertion

• Tim Brandys MD FRCSC

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Indications

• Pneumothorax(Simple,open,tension)

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Pneumothorax

• 10 lung volume loss1 cm Pneumothorax at lateral
  edge 5th rib upright CXR
• 2CM20
• 3CM30

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Indications

• Evacuate Fluid
• Hemothorax
• Effusion(benign,malignant)
• Empyema

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Indications

• Therapeutic
• Pleurodesis
• Intrapleural Chemo.

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Indications

• Suspected lung injury
• Patient to go for
• General Anes.
• Transport
• Positive Press. Ventilation

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Site Selection

• Pneumothorax Mid.clav.line 2nd ICS
• 5th ICS Between Ant. and Mid Ax. Lines
• Pleural Effusion
• 5th ICS Post.Axillary Line
  Loculated Effusion Determined
  Radiologically(U/Sor CT)

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Size of Chest Tube

• Pneumothorax-Small 24 French
• Hemohorax-Large 38 French

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Procedure

• General Tips
• 1. Have everything you need at the bedside.
• 2.Prep and Drape a wide area.
• 3.Have a plan B.

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Procedure

• 1. Consent if appropriate
• 2. Sedation If approprate
• 3. Prep and Drape Predetermined spot

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Procedure

• 1.Local Anesth.
• 2.Aspirate with needle to ensure you are in the
  desired location.

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Procedure

• 5. 2-3cm transverse incision over rib.
• BLUNT dissection over top of lower rib thru
  subcut. and muscle with kelly.
• 6.Puncture Parietal Peritoneum with Kelly
• Pop

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Procedure

• 7. FINGER SWEEP 360
• degrees in pleural space

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Procedure

• 8. Kelly on chest tube and insert in.
• 9. Ensure in far enough and,look for fogging

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Procedure

• 10.Connect to underwater suction,Suture in
  ,Dressing Chest x-ray

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Complications

• 1. Laceration intrathoracic or abdominal
  organs(Finger Sweep)
• 2. Empyema
• 3. Damage Intercostal neurovascular bundle
• 4. Poor Tube position,Kinking
• 5. Subcutaneous Emphysema
• 6. Re-expansion Pulmonary Edema
• (gt 1 l fluid off)

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Exam Questions

• Trauma-How much chest tube drainage mandates
  urgent Thoracotomy?
• How much fluid has to be present to show up on
  CXR as a pleural effusion ?
• What are the surface landmarks commonly used to
  count ICS ?